Robotic Sacrocolpopexy With Mesh For Vaginal Wall Prolapse

About the Surgeon

The vagina is anatomically situated between the rectum and the bladder. The protrusion of various components (cystocele=bladder herniation, enterocele=small bowel herniation, rectocele=rectal herniation) may require surgical fixation. In this chapter we focus on vaginal vault prolapse, a condition in which the entire vaginal vault drops down or falls out after hysterectomy. Up to 8-10% of patients who undergo a hysterectomy, may suffer from this condition. In severe cases, such as the case presented in this video, the top of the vagina may bulge out and be seen between the labia. A non physician may consider this analogous to a sock that is turned inside out.

Non surgical treatment includes the use of pessary. This is a small device placed in the vagina that prevents the prolapse. It is not useful for woman who are sexually active. The device has to be removed periodically and cleaned. Medications such as estrogen replacement may also be considered though this will not help in severe cases of vaginal prolapse. Side effects of estrogen replacement should be discussed. Pelvic floor exercises (Kegels) with or without biofeedback may be considered to strengthen the pelvic musculature.

Surgical treatment may include sacrospinous fixation of the vagina (not covered in this chapter) to the sacrospinal ligament using non absorbable suture. Enterocele repair is concomitantly performed. If a bladder neck procedure is necessary for incontinence, this is typically performed prior to the sacrospinous fixation. Use of the natural orifice (vagina) and therefore lack of abdominal incisions, is the main advantage of this approach.

Robotic assisted laparoscopic sacrocolpopexy may alternatively be performed to correct problems with vaginal prolapse. In essence the vagina is fixed to the sacrum (bone ligament) using mesh (non absorbable permanent screen) to hold the vagina in placed.

Vaginal Vault Prolapse Reduced After Robotic Sacrocolpopexy. Note very short mesh limbs depicted in this illustration.

The bridge of synthetic mesh is used as there is generally inadequate length to bring the vagina and sacrum together. Using a Y shaped mesh, concomitant cystocele and rectocele repair may be performed at the same time. Several Y shaped mesh kits are currently available on the market. First, place a limb of the mesh anterior between the bladder and vagina, and a limb posterior between the rectum and vagina. The mesh is then pulled up and fixed to the sacrum, providing the vagina with support on both sides as well as at the apex.

Open sacral colpopexy has been performed for numerous years. Long term outcomes appear to be durable. Culligan et al reported ~15% failure rate in 245 patients undergoing open procedures at 2 years of follow up.(1) Outcomes of robotic sacrocolpopexy have been present in abstract format at various meetings. Several published series demonstrate comparable failure results as compared to open abdominal sacrocolpopexy. Siddiqui et al reported 8% vs 4%, p=0.16 failure rate in 86 vs. 304 woman undergoing robotic vs. open abdominal sacrocolpopexy. (2) In a comparison of 40 robotic cases and 19 open sacrocolpopexies, Elliott et al reported a 4.2-10% overall cost savings for robotic assisted surgery over the open approach, however, this was dependent on how the authors calculated cost/billing data.(3) Total number of robotic cases performed factored in the overall cost of the robotic procedures. In addition, the shorter hospital stay of 1.0 day robotic vs. 3.3 days open favored the robotic approach. Paraiso et al from Cleveland Clinic performed a randomized control trial of robotic (n=35) vs. laparoscopic (n=33) sacrocolpopexy. They authors found longer operative time with robotic approach, 67 minutes, and increased cost by $1,936. In addition, the authors found a statistically significant increase in pain for the robotic group; however, clinical significance is debatable. Immediate complications and 1-year follow up results were not different between the 2 groups. It is important to point out that the 2 operative surgeons in this study are experts in laparoscopic surgery with tremendous experience, hence their results may not be as easily attained by other surgeons.

Operative steps

Trocar placement:

Robotic assisted laparoscopic sacrocolpopexy trocar placement. RR=right robotic arm, LL=Left robotic arm. Some authors place the 4th arm more cephalad, but we have not found this to be necessary.

We prefer the 4th robotic arm, on the left side as this allows the sigmoid to be pulled over the left side with limited interference.

The patient is placed in trendelenberg position to allow for the omentum and bowel to drop cephalad.

Presacral space dissection: Identify the sacral promontory. Pull the sigmoid to the left, identify the ureter on the right, and appreciate the common iliac pulsations. Going caudal to the pulsations, the sacrum is typically identified with gentle dissection. The preferred instruments are the scissors in the right hand and the bipolar in the left hand. If necessary, a 30 degree down lens may be used depending on anatomy and how cephalad the camera trocar was placed.

Vaginal dissection: Dissect the vagina off the bladder using the avascular plane. A vaginal manipulator controlled by the assistant provides excellent identification of the vagina. The robotic assistant arm may place gentle retraction on the bladder. Inadvertent entry into vagina should be closed with absorbable mesh. Distal dissection should be carried both anteriorly and posteriorly in order to support and prevent cystocele and rectocele component. In the video presented, the limbs are both shorter as the patient had prior surgery for both and only had apical vault prolapse component.

Vaginal apex mesh attachment: completed with CV-2 Gore-Tex suture. This is an excellent suture without memory that is preferred in robotic procedures. The surgeon should be careful not to incorporate vaginal epithelium, ie. no full thickness bites. Usually 6-8 sutures are be placed both anteriorly and posteriorly on the vagina. When working posteriorly, it is prudent to roll the mesh and use the 4th arm to hold the vagina anteriorly to expose the posterior aspect. Avoid blood vessels running anterior to the sacrum, to minimize risk of bleeding. (Blood vessels seen clearly in this video).

Attachment of mesh to the anterior longitudinal ligament: 2 CV-2 Gore-Tex sutures placed in the anterior longitudinal ligaments are placed in the mesh and tied down. Prior to doing so, ensure proper tension on the vagina with the vaginal manipulator removed. Excess mesh then may be trimmed.

Peritoneal Closure: If a peritoneal tunnel is created for the proximal limb (as in this video), less peritoneal closure is necessary. Peritoneum is closed with absorbable suture (2-0 Vycril in this case).

Complications

Mesh erosion may be a significant complication of the procedure. Erosion rates after open procedure have been reported as low as 0.8%(4) and has high as 20% (5). Techniques to minimize erosion include meticulous dissection in the avascular plane between the bladder and vagina anteriorly, proper peritoneal covering of the mesh proximal limb, and 2 layer closure of the vaginal cuff in cases of concomitant hysterectomy. In a smaller series of robotic sacrocolpopexy, mesh erosion was noted in 8/57 woman with concomitant total hysterectomy vs. 0/45 women with supracervical hysterectomy.(6)

Bleeding: Heidi et al from University of Pennsylvania reported similar blood transfusion rates of around 1.5% between open and robotic approach. (Abstract AUGS, September, 2011 Providence, RI).

Other rare complications related to any abdominal surgery may include bowel injury, cystotomy, ureter injury, and ileus.